1.

ANATOMY FISIOLOGY
a) Atrium:
Right atrium
This thin-walled right atrium serves as a storage area for blood and as a blood supply
from the systemic veins of the systemic circulation into the right ventricle then to the
lungs. Blood derived from these veins enter into the right atrium through the superior,
inferior, and coronary vena cava veins. In the mouth of the vena cava there is no true
valve. The thing that separates the vena cava from the atrium is merely the fold of the
valve or the muscle band.
The left atrium
The left atrium receives oxygenated blood from the lungs through all four plulmonary
veins. Between the pulmonary vein and the left atrium there is no true valve. Therefore,
changes in pressure in the left atrium easily reverse the retrograde (retreat) into the lung
vessels. Increased acute left atrial pressure will result in lung dam. The left atrium is
thin-walled and low-pressure. Blood flows from the left atrium into the left ventricle
through the mitral valve.
b) Atrial function as a pump
In normal circumstances blood flows continuously from the large veins into the atrium.
Approximately 70% of this flow flows directly from the atria to the ventricles even
though the atrium has not contracted. Then the atrial contraction holds a 30% additional
charge because the atrium serves only as a primary pump which increases the
effectiveness of the ventricle. The heart can continue to work very satisfactorily in a
normal resting state.

2. DEFINITION
Atrial septal defect or Atrial Septal Defect (ASD) is a septum or septum disturbance
between the right and left atrial space or the abnormal opening in the septum separating
the two atriums resulting in blood flowing from the high-pressure left atrium in the low-
pressure right in the right. The septum does not close completely and makes the left and
right atrial blood flow intermixed.
According to the location of the defect, ASD is grouped into:
a) Atrial septal septum defects
Defects occur in the oval fossa and are often accompanied by oval fossa aneurysms.
b) Atrial septal defect with superior venous sinus defect
 Defects occur near the mouth of the superior vena cava resulting in biatrial
connections. Frequent pulmonary veins of the right lung also undergo anomalies.
There may also be an inferior venaeous sinus venosus type vena, located below the
foramen ovale and joining the base of the inferior vena cava.
c) Primary atrium septal defect
Part of the atrioventricular septal defect and at the top is bounded by the oval fossa
while the bottom is with the atrioventricular valve.
According to its complexity, ASD is classified into:
1) Simple ASD with defects in the septum and around the fossa ovalis (known
as secondery DSA), defects in the lower edge of the septum (DSA primum)
and defects of the VCS estuary (sinus venosus defect), often accompanied
by partial anomaly of pulmonary vein density.
2) The complex ASD is a form of endocardial cushion defect now known as
an atrioventricular septal defect (DSAV) or AV canal. The septal defect of
the atrium sekundum is a disorder in which there is a pathological opening
in place of the oval fossa. The result is a shunt from the left atrium to the
right atrium, with a volume load in the atrium and in the right ventricle.
3. ETIOLOGY
The heart forms during the first 8 weeks of fetal development. It begins as a vacuum
tube, then the partition in the tube develops that eventually becomes a septa (or wall)
dividing the right side of the heart from the left. Atrial septal defect occurs when the
partition process does not occur completely, leaving a hole in the atrial septum.
Some congenital heart defects may have genetic links, either due to defects in genes,
chromosomal abnormalities, or environmental exposure, causing heart problems more
common in certain families. Most atrial septal defects occur sporadically (by chance),
for no apparent reason for their development.
Factors that cause ASD include:
a) Prenatal Factors
1) Mother suffered from Rubella infection
2) Mother of alcoholism
3) Mother's age is more than 40 years
4) Mother suffers from IDDM
5) Mother taking sedative or herbal medicine
b) Genetic factors
1) Children born previously suffered from PJB
2) Father or mother suffering from PJB
3) Chromosome disorders such as Down syndrome
4) Born with other congenital abnormalities

4. CLINICAL MANIFESTATION
Most ASD sufferers do not show symptoms (asymptomatically) in the minor, except in
large ASDs that can cause heart failure conditions in the first year of life in about 5%
of patients. Incidence of heart failure increases in the 4th and 5th decades, accompanied
by impaired electrical activity of the heart (arrhythmia). Symptoms that appear in
infancy and childhood are the presence of recurrent lower respiratory tract infections,
characterized by complaints of cough and heat loss (tanpapilek). In addition, symptoms
of heart failure (in large ASD) may be shortness of breath, difficulty breast feeding,
failure to grow in infants or quickly accomplished during physical activity in older
children. Furthermore, by physical examination and investigation such as electro-
 cardiography (ECG), chest rontgent and echo-cardiography, diagnosis of ASD can be
enforced.
SIGNS & SYMPTOMS
Symptoms that usually appear on ASD are:
a) The existence of dipsnea
b) The tendency of infection of the airway
c) Palpitations
d) The right and left atrium is enlarged
e) Diastolic increases
f) Systolic low

5. PATHOPHYSIOLOGY
In the case of an uncomplicated Atrial Septal Defect, the oxygen-containing blood of
the Left Atrium flows into the Right Atrium but not vice versa. The flow through the
effects is a process due to the size and complain of the atrium. Normally after the baby
is born the right ventricular complain becomes larger than the left ventricle which
causes the right ventricular wall thickness to decrease. This also results in the volume
and size of the right atrium and right ventricle on the rise.
If the right ventricular complain continues to decrease as the shunt's increasing load
from the left ordinary drop is reduced. At one time Eisenmenger's syndrome can occur
due to pulmonary vascular disease that continues to gain weight. The direction of the
shunt can also be changed from the right to the left so that the systemic blood circulation
contains a lot of oxygen-low blood resulting in hypoxemia and cyanosis.\

6. COMPLICATIONS
Frequent Complications:
a) Heart failure
b) Pulmonary vascular disease
c) Endocarditis
d) Pulmonary vascular obstruction (pulmonary hypertension)
e) Arrhythmias
f) Cardiac arrest
 g) ASD and VSD

7. SUPPORTING EXAMINATION
Diagnostic checks that are often performed on ASD sufferers are:
a) Chest X-ray
In ASD patients with a significant shunt, chest radiograph AP indicates a
prominent right atrium, and with prominent pulmonary cones. The heart is only
slightly enlarged and the lung vascularization increases with the size of the
shunt.
b) Electrocardiography
Shows the RBBB pattern at 95%, which indicates the right ventricular volume
load. The axis deviation of the right axis deviation on the ASDsecondum
distinguishes it from the primum defect showing the left axis deviation. AV I
block (PR interval lengthening) is present in 10% of cases of sekundum defects
c) Echocardiography
The main purpose of echocardiography examination in ASD is to evaluate the
shunt from left to right at the atrial level, among others:
1) Identify appropriately the defect between the two atria
2) Visualize the whole pulmonary vein relationship
3) Get rid of other additional lesions
4) Assess the size of the heart chambers (dilatation)
d) Cardiac catheterization
Patients in surgery without cardiac catheterization, catheterization is only done
if there is doubt about the presence of comorbidities or pulmonary hypertension.
e) MRI (Magnetic Resonance Imaging)
This tool can detect anomalous venous estuaries. It can also be used to measure
large defects and estimate the amount of shunt flow.

8. MANAGEMENT
1) Surgery
For practical purposes, patients with atrial defect atrial defects are referred to a
surgeon for closure if the diagnosis is certain. The argument about cardiac
surgery based on the size of the shunt puts more trust in the data than the reason
 given. With an inexplicable atrial defect with shunt from left to right in a child
older than 3 years, closure is reasonable. To be detected, the shunt from left to
right should allow the QP / QS ratio to be at least 1.5: 1; therefore noting the
existence of a shunt is sufficient evidence to move forward. In the first or second
year, there are some benefits of delaying until it is certain that the defect will
not close spontaneously. After the age of 3 years, further delay is rarely justified.
The primary indication of closure of the atrial septal defect is to prevent
abdominal pulmonary vascular disease. Prevention of future rhythm problems
and the occurrence of congestive heart failure may later be considered, but in
fact the defect may be closed later if the problem occurs. Now the risk of heart
surgery for the atrial defect atrium of the sekundum varieties is completely zero.
Of the 430 patients who were operated at Children's Hospital of Boston, there
was no mortality except for a very sick little baby who had patented ductus
arteriosus binding. The possibility of imperfect closure at rare surgery.
Complications later after surgery are rare and especially problematic with atrial
rhythm. In contrast to this experience is a very devastating pulmonary vascular
obstruction problem in 5-10 percent of patients, who suffer from this disease.
The obstructive pulmonary vascular disease is almost always lethal in a few
years and in itself is reason enough to consider surgical repair of all atrial defects

2) Closure of the Atrium Section Adhesive Detection with a catheter.

A double umbrella device incorporated with a cardiac catheter is now used to
cover many atrial defects. Smaller and more centrally located defects are
particularly suitable for this approach. The apparent difficulty of nearby
atrioventricular valves and other structures, such as the orifices of the vena cava,
is real and until now, the system for inserting a large enough device covering a
large defect is not available. The desire to avoid intrathoracic cuts and open the
heart is clear. The most important step in closing the transiteter atrial defect is
the proper assessment of the number, size and location of the defect. Defects
greater than 25 mm in diameter, multiple defects include defects outside the
oval fossa, venous sinus defects that extend into the vena cava, and defects with
tissue edges less than 3-6 mm from the tricuspid valve or right pulmonary veins
are avoided.
 For sufferers with suitable defects, the size is determined by inflating the
balloon and measuring the stretched diameter. The selected umbrella is 80%
larger than the outstretched diameter of the defect. The distal arm of the
umbrella is opened in the left atrium and is pulled slowly but firmly bending the
bulkhead to the right. Then, the right side arm is opened and the umbrella is
pushed into a neutral position. The exact location is confirmed and the umbrella
is released. Patients monitored overnight, the next day came home and crushed
with antibiotic prophylaxis for 6-9 months. All patients with ASD should
undergo a closure action on the defect, because ASD can not close
spontaneously, and if not closed will cause various complications in adulthood.
But when therapy and action need to be done depends largely on the size of the
blood flow (shunt) and the presence or absence of congestive heart failure,
increased pulmonary vascular pressure (pulmonary hypertension) and other
complications. Until 5 years ago, all ASDs could only be treated with open heart
surgery. ASD closing operations either with direct stitching or using patches
have been done for more than 40 years, first performed in 1953 by dr. Gibbson
in the United States, following the discovery of a cardio-pulmonary bypass
machine a year earlier.
This surgery alone, when performed at the right time (not too late) gives
satisfactory results, with minimal risk (0-1% operational mortality rate, low
morbidity). Murphy JG, et.al reported survival after surgery 98% in follow-up
27 years after surgery, in patients who underwent surgery at age less than 11
years. The older age during surgery then the survival will decrease, related to
the occurrence of complications such as increased pressure on the pulmonary
vasculature

3) Non-surgical intervention therapy

Aso is a special tool designed to seal non-surgical ASD type sekundum which
is mounted through a catheter by percutaneous blood vessels in the groin
(femoral artery). This tool consists of 2
9. NURSING ASSESMENT
The data collected or reviewed include:
1) Patient identity
Name, age, gender, nation, occupation, education, religion, address.
2) The main complaint
The main complaints are usually felt in cases of ASD is tightness, anxiety, in
children or babies do not want to suck, difficulty sleeping, patients feel tired
3) History of the disease now
In children usually experience shortness of breath, sweating a lot and there is a
swelling in tetepi legs usually depends on the degree and defects that occur.
4) Past medical history
a) Prenatal History
It is estimated that there is an abnormality in the mother's throat (rubella
ruby infection), there may be a history of alcohol use and medication as
well as DM disease in the mother
b) Intra natal
A history of pregnancy is usually normal and induced
c) History of the neonate
 Respiratory disorder is usually congested, takipnue
 Children fussy and in pain
 Child growth is inhibited
 There is edema in the limbs and hepatomegaly
 Sosial Low socioeconomic families\
5) Family disease history
a) The existence of the family whether it is one or two people who have
heart defects disorder
b) Hereditary disease
c) Congenital or congenital disease
6) Psychosocial
a) Decreased pern in social and family activities
b) Anxiety, kwatir, fear, stress associated with illness
 7) Physical Examination
a) Breathing
Shortness of breath, retraction of the jugular vein, intercostal spine and
epigastric region. Chest diameter increases
b) Blood
Strong, hyperdynamic cardiac impulses are particularly prominent in
the left ventricle. Vibrated noisy voices or nuts on the chest wall, in
ASD vibration palpable palpable between 2nd or 3rd left ribs. In very
large defects are often not palpable vibration noisy because the pressure
in the left ventricle the same right ventricle.
c) Brain
Hyperemic fingertips
d) Bleeder
Decreased urine production
e) Bowel
Hepatomegaly or splenomegaly may be seen
f) Bone
There is no bone disorder

10. NURSING DIAGNOSE

a) High risk of decreased cardiac output related to structural defects.
b) activity intolerance related to oxygen transport system interference
c) Changes in growth and development related to the inadequacy of oxygen and
nutrients in tissues; social isolation.
d) High risk of infection related to weak physical status.
e) High risk of injury (complications) related to heart conditions and therapy
f) Changes in family processes related to having a child with heart disease (ASD)
 11. NURSING INTERVENTION

NO DIAGNOSE NOC NIC

1. High risk of decreased clients will show 1. Give digoxin
cardiac output related to improvement in cardiac according to the
structural defects output. With the criteria of program, using
result: vigilance made to
a) cardiac, blood prevent toxicity.
pressure, and 2. apply afterload drugs
peripheral perfusion according to the
are at normal age- program.
appropriate limits. 3. give diuretics
b) Adequate urine according to the
output (between 0.5 - program
2ml / kgbb,
depending on age
2. activity intolerance the client maintains an 1. Provide frequent rest
related to oxygen adequate level of energy periods and
transport system without additional stress. uninterrupted sleep
interference results criteria; periods.
a) The child determines 2. Encourage calm games
and performs and activities
activities appropriate 3. Help the child choose
to the ability. activities that are
b) \Children get proper appropriate for age,
rest / sleep time condition, and ability.
4. Avoid extreme
environmental
temperatures because
hyperthermia or
hypothermia increase
oxygen demand
5. implement actions to
decrease anxiety.
 6. respond immediately
to crying or other
expressions of distress
Changes in growth and patients follow the weight 1. give a balanced diet
development related to growth curve and height. The high nutrition to
the inadequacy of oxygen child has the opportunity to achieve adequate
and nutrients in tissues; participate in activities that growth.
social isolation match the age of the outcome 2. Monitor height and
criteria; weight, draw on
a) Children achieve the growth charts to
most adequate determine growth
growth. trends.
b) Children perform 3. Can provide iron
activities according supplements to
to age overcome anemia,
c) Children do not when recommended.
experience social 4. Encourage age-
isolation appropriate activities.
5. emphasize that the
child has the same
need for socialization
as any other child.
6. Allow the child to
organize his space
High risk of infection client shows no signs of 1. avoid contact with
related to weak physical infection of outcome criteria; infected individual
status a) Clien are free from 2. give adequate rest
infection 3. provide optimal
nutrition to support
tubu defenses
High risk of injury client / family recognizes 1. Family finger to
(complications) related to signs of early complications. recognize signs, signs
Results criteria; of complications,
heart conditions and a) Families recognize congestive heart
therapy signs of failure;
complications and  tachycardia,
take appropriate especially during
action. rest and mild
b) The client / family activity.
demonstrates an  Tachypnoea
understanding of  much sweat on the
diagnostic and scalp, especially in
surgical tests infants.
 Fatigue
 weight gain
arriving!
 Distress breathing
 toxicity of digoxin
 Vomiting (early
signs)
 Nausea
 Anorexia
 bradycard.
 Dysrhythmias
 increased effort of
breathing-
retraction snoring,
coughing,
cyanosis.
 Hypoxemia-
cyanosis, anxiety.
 pale cardiovascular
collapse, cyanosis,
hypotonia.
 2. Learn the family to do
interference during
hypersianotic attacks
 place the child in
the knee position!
Chest with raised
head and chest.
 stay calm.
 give 100% oxygen
with a face mask
when present.
 contact
practitioners
3. explain or clarify
information provided
by practitioners and
surgeons on the family
4. Prepare children and
parents for the
procedure.
5. bantu make family
decisions related to
surgery.
6. gali feel about the
choice of surgery
Changes in family Client / family experienced 1. Discuss with
processes related to decreased fear and client parents and
having a child with heart anxiety showing positive children (when
disease (ASD) coping behavior of outcomes appropriate) about
criteria; their fears and
a) The family discusses problems of heart
fear and anxiety defects and
physical symptoms
b) The family faces the in children as this
child's symptoms in a often causes
positive way anxiety / fear.
2. Encourage families
to participate in
child care during
hospitalization to
facilitate better
coping at home.
3. Encourage families
to include others in
the care of children
to prevent fatigue
in themselves.
4. Assist families in
determining
physical activity
and appropriate
discipline methods
for children
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